=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306055504
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LANNAE PHELPS D.D.S., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2007
-----------------------------------------------------
Last Update Date | 08/08/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 221 S JEFFERS ST SUITE #1
-----------------------------------------------------
City | NORTH PLATTE
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 69101-5371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-534-4040
-----------------------------------------------------
Fax | 308-534-1087
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 846
-----------------------------------------------------
City | NORTH PLATTE
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 69103-0846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-534-4040
-----------------------------------------------------
Fax | 308-534-1087
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | LANNAE LYNN PHELPS
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 308-534-4040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 6557
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------